Experts are calling for Queensland to scrap its blanket locked door policy in mental health units, saying there is overwhelming evidence it harms patients.
Queensland is the only state in Australia that maintains the policy, which requires that all entry and exit doors on acute mental health inpatient units in public hospitals are locked.
That applies to all patients, whether they are there voluntarily or not.
Advocates say the policy, introduced in 2013, goes against Queensland's Human Rights Act and Mental Health Act, as well as the UN Convention on the Rights of Persons with Disabilities.
Neeraj Gill co-authored an article in 2021 out of Griffith University on the policy, along with senior psychiatrists and academics from Queensland universities, and says the policy doesn't promote patient recovery.
"If you have a physical illness, you're admitted to an open ward, but if you have a mental illness, irrespective of whatever it is, you're admitted to a locked ward," Dr Gill said.
The Mental Health Act (2016) Queensland requires that all treatment should be carried out in a way that is least restrictive and promotes patient recovery.
Dr Gill said the policy is at odds with this intention, and he recommended a full review of the blanket policy and that mental health services must use discretion about when to lock wards.
Last year the Queensland government failed to allow full access to the UN Subcommittee on the Prevention of Torture to inspect their "closed environments" – which included locked wards.
'My human rights have been abused'
Rebecca – whose name has been changed to protect her identity — has been in Queensland inpatient units twice since 2017.
She was working in healthcare at the time and both times, she was on involuntary acts.
"I felt that my human rights have been abused," she said.
"I went to leave at one point and was held down by six staff.
"I pressed the emergency call button on my Apple watch, and it called triple-0, and that would've recorded me yelling, screaming, and being frightened and held down."
Rebecca said she doesn’t know if that call was ever reviewed.
Patients afraid to ask to leave
Under the guidance of the securing adult acute mental health inpatient units policy, it is a requirement that voluntary patients and visitors should be able to move freely in and out of units.
Queensland's Public Advocate John Chesterman said that doesn't translate easily to real-life practice.
"Sometimes people don't realise they're free to be able to move in and out," Dr Chesterman said.
"You need to get permission from staff members to be able to leave if you're a voluntary patient, and that can lead to assessments of whether it is appropriate for you to leave."
Matilda Alexander, CEO of the Queensland Advocacy for Inclusion, said there were many cases when patients asked to leave but instead had their situation escalated to an involuntary order.
Rebecca said this was a common occurrence on the wards.
"It is not obvious that you can leave if you want to," she said.
She also said it was difficult to provide feedback to staff.
“You can put written complaints into the complaints box on the ward, but nothing is done about it,” she said.
Calls for change
Dr Chesterman, Ms Alexander, and Rebecca want the locked ward policy to be abolished.
"It should be replaced with a discretionary locked wards policy so that individual units should be able to determine, consistent with a human-rights framework, whether the particular unit is locked," Dr Chesterman said.
They say it interferes with the right not to be arbitrarily deprived of liberty, which falls under the state's human rights act.
Under the act, the Queensland government has an obligation to not detain people, especially when it is not authorised by law.
"It's a clear and continuous breach of human rights, the right to liberty and security in person," Ms Alexander said.
"It is not sufficient to hold somebody who is in hospital voluntarily behind the closed door."
Experts also say it goes against the Convention on the Rights of Persons with Disabilities.
Why was the policy introduced?
The policy was introduced in December, 2013 under Campbell Newman's LNP government.
The directive was issued out of concern for the number of people who were "absent without permission".
This could mean an involuntary patient had left an acute mental health ward without approval or was on leave in the community but didn't return to the ward when required.
But, according to Dr Gill, international literature shows a blanket policy, without individualised consideration of risk, doesn't reduce absconding.
"There was no benefit of locked wards when it comes to suicide, suicide attempts or absconding," he said.
His report notes that locking patients without discretion leads to reduced self-esteem and autonomy, a sense of exclusion, confinement and stigma.
It also results in lower satisfaction with services and higher rates of medication refusal.
Rebecca said in the locked wards, patients were often distressed.
A spokesperson for Queensland Health said the policy had been "essential" in "protecting the safety of patients and the community" and had reduced rates of patients absent without approval.
Alternative solutions
There are calls to implement a safe wards program as an alternative solution to the locked ward policy.
The program, which originated in the UK, was designed to reduce conflict and containment on psychiatric wards.
It involves a range of interventions, including improved communication between staff and patients, the provision of de-escalation strategies, the use of positive language, and distraction and sensory modulation to manage anger.
The safe wards program was trialled on the Gold Coast in 2021.
A Queensland Health spokesperson said the trial used discretionary locking at an eight-bed, short-stay inpatient unit.
"The results of the evaluation of the trial to date have been positive with no increase in absence without approval," the spokesperson said.
Dr Chesterman said he supports Queensland moving towards a safe ward program.
So too does the Queensland Mental Health Commission.
"The commission supports a safe wards approach that includes reducing restrictive practices and local decision-making about the need to lock wards," a spokesperson said.
Rebecca said she wants patients to have more autonomy over their own treatment in Queensland's inpatient unit.
"I believe that we should have [human rights legislation] influence in Queensland specifically, but in Australia overall, so that we can have fully informed consent," she said.
